Stitches Still Left 3 Years After Tummy Tuck?

8 months ago, I had an oozing wound on my tummy tuck scar, just above the mons area. My plastic surgeon went in to look for a leftover stitch but could not locate one. He did this twice. One one occasion, he went pretty deep with the needle and it hurt very bad down in the pubic area! He never did find a stitch, but it came out on its own. The area where he explored is still sensitive. Now, the mons area on that side is swollen and feels like pinching. Could it be another stitch?

Doctor Answers (17)

Use of Dissolving VS Permanent Stitches in Tummy Tuck Surgery?

February 9th, 2011

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

A review of my colleagues’ responses may give the casual RealSelf reader the wrong impression on this topic. In breaking with some of my more prolific RealSelf “2 lines or less” responders, I think this topic is important and deserves a proper explanation.

From the beginning of time, surgeons have used multiple ways of bringing cut tissues together, from using fire ants to bite and hold the tissues and then twisting their heads off (which would not go over well with PETA and current sterility regulations), to using rubber tree sap on strips to using silk, horse tail hairs or cotton strands to silver wires. Everything has been tried. In time, sutures (stitches) became divided into 2 large groups: very long lasting (Permanent) and Dissolving. Further divisions into single strand VS multiple strand (rope like) stitches help in categorizing stitches.

As Surgery evolved and the science of surgery has grown into multiple specialties, surgeons availed themselves of a certain suture for a certain job; picking the suture which provided the best duration of strength for the interval required for healing.

Simply put, a stitch is a foreign body (just like a pacemaker, breast implant, artificial lens, artificial hip, bullet, heart valve, etc). Some people tolerate them extremely well while others do not. As a result, in picking a specific suture, surgeons choose one whose duration and strength correspond to how long it will be needed before the body’s healing and scar tissue are sufficient to maintain the tissues or structure / implant in place. For example, when we stitch facial cuts, we universally clean the wounds and close them in several layers with dissolving sutures. Since there is no constant pull on the skin edges, we do not need to rely on long-lasting or permanent stitches. Similarly, in eye surgery where only a temporary hold is needed while the body is healing, permanent stitches are not needed and small dissolving stitches are commonly used (except for lenses). The heart and blood vessels pose different challenges. The heart beats 60 to 120 times a minute. The heart valves snap open and shut this many times until the valve degenerates and needs changing or your heart stops. In other words, non-stop action for the rest of your life. If a new heart valve was stitched with the best long lasting dissolving stitches, it would not take too many beats after the last stitch has dissolved for the valve to be blown away from the heart by the force of contraction. Similarly, all vessels (from the biggest in the body to coronary bypass grafts to those stitched together under the microscope as when fingers are put back on) are joined with permanent stitches to avoid their coming apart. The same applies to shoulder, hips and knee joints which experience large forces of tension and compression.
When it comes to abdominal hernia surgery, we almost always use permanent stitches because the human abdomen is under a significant amount of permanent tension. Using dissolving stitches in hernia surgery invariably results in recurrence of the bulging.

Which brings us to the topic of THE proper closure Tummy Tuck muscle repairs and the transverse wound. The old joke remains ; 2 Plastic surgeons in the room – 3 different opinions (at least). (And if allowed, our discussions resemble those seen in the British Parliament. Those who have seen it, will understand).
Tummy Tuck Surgery and Body Contouring after massive weight loss was influenced and advanced by one surgeon more than many others – Dr. Ted Lockwood of Kansas. Dr. Lockwood described the strength layer of the lower abdomen and the thigh – the SFS, which allows us to lift the thighs as part of a tummy tuck. He also described the High Lateral Tension Abdominoplasty, a very innovative tummy tuck method upon which many other techniques are based.

A concept known to ALL Plastic surgeons is that to obtain an attractive, narrow scar, tension on the (superficial) skin closure must be avoided by all means. Tension on the skin always results in wide, ugly scar. How then can we really pull the tummy skin and flatten it but avoid the tension being transmitted to the top layer of the skin? We use deeper stitches to do all the pulling along the deep layers allowing the superficial skin edges just “kiss” and put together without tension. The resulting scars are always nice. This principal is used in Facelift surgery and in Tummy Tuck surgery. IF I am to smooth the tummy, lift my patient’s thighs, smoothing them and the lower tummy, I put deep tension holding anchor stitches in the SFS layer. On this point, the vast majority of Plastic surgeons would agree.

The question comes, what happens to the superficial, visible scar when the deep stitches dissolve?

What do you think? What does your common sense tell you?

WHY would we need permanent stitches in the heart, in blood vessels, to anchor joints, but somehow the weight of the thighs can now only be supported by our scar tissue without pulling on the superficial skin? That is where Plastic surgeons disagree.

Having seen multiple previously beautiful, hairline thin Tummy Tuck scars widen months after surgery when the deep dissolving stitches went away and the weight of the lower aspect of the wound WAS transmitted to the scar, I am convinced that there IS a place for permanent stitches in the deep SFS layer in Tummy Tuck surgery. Dr. Lockwood thought so and passionately advocated the use of braided permanent stitches (Neurolon) in the deep layer. (The same stitch you appear to have by the way).

And now, for the sake of complete disclosure, the dirty secret. ALL stitches can spit. Both dissolving (Vicryl, PDS etc) and permanent. Long lasting dissolving stitches whose knots are often stiff can be very annoying to patients and once they are pushed close to the skin, they are extruded very much like the permanent stitch you wrote about. In both cases, the removal of the suture is followed by rapid healing.

The ONLY question you need to ask yourself and your surgeon – What is better FOR ME - a CHANCE of spitting one or more deep permanent stitches as a payment for a hairline scar and smooth tummy and thighs OR the slightly smaller chance of spitting long-lasting dissolving stitches (such as PDS) with a near certainty of tension-related, delayed scar widening?

Stitches

February 7th, 2011

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Usually the sutures used on the skin are absorbable and should go away over time (months). However, many times the deeper stitches are permanent and do not absorb. Normally these are surrounded in scar tissue and help hold the muscles repair in place. Occasionally, the body try to extrude the permanent stitch like what happened with you. I would suggest discussing your current symptoms with your plastic surgeon.

Tummy Tuck Pictures

Type of stitch/suture material used in deep closure of rectus abdominis diastasis in tummy tuck

February 9th, 2011

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

I was equeally interested in reading my colleagues responses. I intially used absorbable sutures (Maxon) but was dissatisfied with the long term resutls and so I returned to permanent sutures for the past 12 years and have been pleased with the relatively low rate of permanent extrusion. When fixing hernias, we tend to use permanent materials and so I don't understand the reluctance of some to use these materials.

Permanent sutures for skin flap closure not the best solution...

February 9th, 2011

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Some surgeons got in the habit of using permanent suture materials in the deep tissues as a result of being trained by their elders, who in turn were trained by WWII veterans. This is a remnant of classical military general surgical training, where abdomens were routinely closed with "40 cotton blues" and the like (inexpensive, strong, and available materials in crazy world where everything was in short supply), resulting in predictably profound inflammatory reactions in tissues.

Nowadays, we have fantastic sutures available with properties we could only have dreamed of a generation ago. Some surgeons still use the old fashioned stuff, because all surgeons basically hate change.

There are many good kinds of sutures that dissolve promptly when their strength is no longer needed, and resist infection through special coatings. Modern surgeons use these more advanced materials because they are better and demonstrate better outcomes in clinical studies (evidence based medicine). Some surgeons however, still resist changing to newer (more expensive) suture materials. This is the result....

Chronic suture exposure

February 9th, 2011

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

It's very atypical and it depends on the suture material that your plastic surgeon used, but yes, it very likely is another suture. Eventually they'll all come out and your plastic surgeon will probably stop using that sort of suture even if you're the only patient it has happened to in his practice lifetime. Sorry to hear this happened but fortunately they just need to be removed and it improves. Keep your incision nice and clean as the new scar forms around these open wound areas. Best wishes,

Spitting sutures?

February 8th, 2011

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

As suggested by the other panelists, there could be more sutures that are trying to work their way out and so it would be helpful for you to see a Board Certified Plastic Surgeon in your area to evaluate.

Tummy tuck stitches may still be present.

February 8th, 2011

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

There are 2 types of stitches available for use in a tummy tuck. One type is permanent and one type dissolves. The stitches you have spitting out are permanent ones. There may be other sutures trying to work their way out. Discuss with your plastic surgeon your concerns and request local anesthesia if the area is explored again.

Why use non absorbable suture?

February 8th, 2011

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

Non absorbable suture has been used to close the superficial fascia in abdominoplasty because it was felt that repair of this layer provided better results and this layer would not have enough strength when the absorbables go away. Spitting of these is a problem and is the reason many surgeons no longer use non absorbables for this layer.

Spitting sutures years after TT

February 7th, 2011

{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}

I have been in practice over 20 years. I used to use non-absorbable sutures in the deeper layers of abdominoplasty incision closures, but found that a few women "spit" the sutures out years later. Most of them were right around three years after the TT. Several women kept spitting them and two I ended up taking back to surgery, excising the scars and removing all the permanent sutures. I closed them with absorbable sutures and the problem was gone. It may seem extreme, but the surgery was much less invasive than the original TT, the recovery was shorter and what had become a painful chronic condition was cured. You may have another suture working its way out. If it becomes a recurring problem you may need surgery again.

These answers are for educational purposes and should not be relied upon as
a substitute for medical advice you may receive from your physician. If you
have a medical emergency, please call 911. These answers do not constitute
or initiate a patient/doctor relationship.